ENEMA.pdf
- 1. ENEMA (Lower Bowel Irrigation) AND RECTAL TUBE DEFINITION The process of introducing a stream of solution into the rectum and/or lower colon and draining it off by natural or artificial means, the rectal tube facilities expelling gas. TERMINOLOGY • Retention Enema- Solution introduced into lower bowel but not expelled, it may serve as a local medication or soothing agent, it may also be retained so the body can absorb it to bring about sedation, hydration or nourishment. The type of solution may cause fluid to be withdrawn from the body, as in the case of cerebral edema. Retained fluids may also help cool the body or stop local hemorrhage. • Non retention Enema- Solution given with the intentions of its being expelled within few minutes, along with feces, gas and other substances • Harris Flush- Lower bowel irrigation which promotes the expulsion of flatus (up and down flush) from the intestines. This is especially helpful with post-operative patients, whose those intestinal tracts have been at rest and now need assistance in reestablishing normal peristalsis. • Feces- Body wastes, including food residue, bacteria, epithelium and mucus discharged from the bowels via the anus • Flatus: Gas in the digestive tract. • Anus: Outlet of the rectum. • Rectum: Lower por ion of the large intestine, about 5 inches long in the adult. It is located between the sigmoid and the anus. • Colon: The large intestine, from cecum to rectum, 4 to 6 feet long in the adult. It is divided into ascending, transverse and descending columns. • Peristalsis: A progressive contract ion movement which occurs involuntarily bellow tubes of the body, especially in alimentary canal. Distention of the tube increases peristalsis. The construction and relaxation of the musculature forces contents thought the tube. CLASSIFICATION OF ENEMA ACCORDING TO THEIR ACTION 1. CLEANSING ENEMA- Stimulates peristalsis by irritating the column and rectum and/or by distending the intestine with the volume of fluid introduced. a. Two (2) kinds of Cleansing Enema: (a) High Enema- is given to clean as much of the colon as possible. The fluid or solution is given at a higher pressure than for a low enema. 1. Position of Patient: From left-lateral to dorsal recumbent position to right lateral during the administration. (b) Low Enema-is given at a lower (c) pressure than the high enema; it is used to clean the rectum and the sigmoid colon only. 1. Position of the patient: Left-side lying position only during administration. 2. CARMINATIVE ENEMA- is given primarily to expel flatus. For adults. 60-180 ml. of fluids is instilled. 3. RETENTION ENEMA- introduces oil into the rectum and sigmoid colon for one hour or more (long period of time). It acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating passage of the feces. 4. RETURN FLOW- referred to as the Harris flush or colonic irrigation, is used to expel flatus. NOTE: ENEMAS ARE ONLY DONE PER DOCTOR'S ORDER
- 2. 5. Sedative enema- To allay irritability and to induce sleep. Drug prescribed is dissolved in 2-3 oz. thin, boiled starch solution or olive oil. Drugs used: Choral hydrate paraldehyde and Sodium Bromide. 6. Stimulating enema- To stimulate body processes. a) Black coffee- 6-8 oz. b) Brandy-2 oz. Hot water- 5-6 oz. c) As prescribe. 7. Medicated or medicinal enema- To administer a drug that cannot be taken by mouth. As prescribe. A. Non-Retention Enema Special considerations: 1. Know the purpose for which the enema has been ordered. 2. See to it that the patient is in relaxed and comfortable position. 3. Avoid stimulating defecation while solution is being introduced by: a. keeping out of sight factors that may stimulate peristalsis. b. introducing the solution slowly and gently. c. maintaining a more or less even or same pressure. 4. Ensure privacy. 5. Give the enema with the patient in bed, not sitting on commode or toilet bowl. 6. When dealing with a patient with abdominal surgery exercise specially care avoid increasing distention. 7. If the patient weak or has cardiac condition, do not leave the patient alone. 8. If the patient has poor anal sphincter control, give the enema with the patient on a bedpan and with the buttocks slightly elevated. 9. See to it that most of the solution introduced is expelled. 10. Discontinued the enema at once and report if unusual difficulty occurs or if the patient develops severe pain or a reaction. PREPARATION 1. Equipment: Enema Tray with: • Irrigator can • Rubber tugging (24 in.) with a glass connecting tube • Clamp or stopcock • Rectal tube- Fr. 22-24 • Lubricant-usually solid vase line • Tissue paper • Solution ordered- 750-15000 cc. or as ordered; at 115-120°F (on preparation) • Rubber protector • Treatment blanket (if available) • Kidney basin • Bedpan with cover Preparation at the Nurses Station: 1. Attach to the irrigation can, the rubber tubing with a glass connecting tube, 2. Place the clamp or stepcacktand, close it. 3. Place a small amount of the lubricant in tissue paper and wrap the tip of the rectal. 4. Attach the rectal tube to the glass connecting tube, 5. Pour the prescribed solution into the irrigator can. Cover it with the treatment towel. B. PATIENT AND UNIT: 1. Bring the prepared equipment to the bedside. 2. Explain the treatment to the patient and gain his cooperation. 3. Ask the patient's visitors to leave the room and close the door. Screen the bed if in a general ward. 4. Adjust temperature and ventilation of the room.
- 3. 5. Have patient empty his bladder. 6. Lower or adjust bed to a flat position, have only one pillow under the patient's head. PROCEDURE 1. Untuck the top sheet; or preferable replace it with the treatment blanket. Loosening the top sheet allows easy change of position. The use of a treatment blanket prevents soiling of the top sheet as well as unpleasant odor of feces in the room. 2. Place the rubber protector under the buttocks. To prevent soiling of mattress and bottom sheet. 3. Assist the patient to assume the desired position. a. Usually he is placed in left lateral position with the buttocks closed to the edge of the mattress b. If the above position is contraindicated or not well tolerated by the patient, he may be placed in dorsal recumbent position with buttocks slightly elevated. The proper position of the patient facilitates the gravitational inflow of the solution as well as provides relaxation of the abdominal muscles, enabling the patient to retain the solution being introduced. Drape him accordingly. Minimal exposure and warmth provided by proper draping minimizes tension that impedes the relaxation necessary for the success of the treatment. 4. Hang the irrigator can in such away the level of the solution is not more than 18 inches from the rectum. Such height of the column of liquid provides the pressure necessary to overcome resistance to the flow of the solution without causing strong colonic contractions. 5. Lubricate 2 inches of the tip of the rectal tube taking not to plug the opening. Lubrication reduces friction between the rectal tube wall of the canal, thus ensuring a painless and easy insertion of the tube. 6. Holding the rectal tube about 3 inches from the tip and over kidney basin or bedpan, open the clamp and allow a small amount of the solution to run through it. Such hold guides the nurse in ensuring the insertion of the proper length of the rectal tube. Lose the clamp. Expelling a small amount of the solution remove the air in the tubing, that may stimulate vigorous stimulation thereby causing difficulty or inability of retaining the solution being introduced. 7. With one hand, separate the buttocks in order to open up the anal folds. To prevent trauma and facilitate the insertion of the rectal tip. Asking the patient to breathe thru the mouth or to take deep breath, insert the lubricated rectal tip slowly and gently with rotating motion up to 2 inches, pause for a while, then insert it more up to 4 inches. Such acts prevent straining and therapy reduces intra-abdominal pressures. Observing care and gentleness in the blind insertion of the rectal tube into a closed cavity or canal prevents injury. The introduction of any foreign body into the anal canal and rectum causes pressure muscles stretching which in turn stimulates the nerve receptors resulting in the contraction of the walls of the colon and peristalsis. A brief pause allows time for relaxation. 8. Open the clamp and allow the solution to enter the rectum slowly. A fast inflow of the solution initiates strong contractions of the colon and thereby prevents retention of sufficient fluid necessary for the effectiveness of the treatment. 9. While the solution is flowing: a. Ask the patient to breathe thru the mouth. To prevent straining.
- 4. b. Encourage the patient to hold the solution. To help the patient retain an adequate amount for more effective treatment. c. If the patient is apprehensive divert his attention. d. Look into the irrigator can once in a while. To check on the flow of the solution and to determine the amount of solution already introduced. e. Adjust the flow of solution accordingly by adjusting the height of the irrigator can. To ensure the proper flow of solution, neither too fast nor too slow. 10. When the patient has strong desire to or before the irrigator can become empty, close the clamp, pinch the rectal tube close to the anus, and apply slight pressure over the anal region. Pinching the tube as it is withdrawn prevents dripping of the solution and soiling of the bedlinens. Slight annual pressure over the anal region inhibits the urge to defecate; thus, enabling the patient to retain the solution for a few minutes and producing a better effect. 11. Wrap the contaminated end of the rectal paper, disconnect the rectal tube and place it in the kidney basin. Such precautions prevent the spread of microorganisms. 12. Instruct him to retain the solution about 3-5 minutes. This allows better softening of the fecal mass in the rectum. 13. Place the patient on a bedpan; elevate backrest; place the call light and tissue paper within reach. An upright position increases intra-abdominal pressure therapy aiding in expelling the return flow. Leave the patient alone to expel the enema unless he must be assisted or supported because of his condition. Presence of persons makes the patient's felt embarrassed when defecating, causing difficulty in elimination. The nurse remaining close efforts safety for the patient who is weak, or has a cardiac condition, etc. If the patient uses the toilet advise him not to flush until the results have been observe. Accurate observation and proper evaluation of treatment given contribute to the adequate assessment of the patient's needs. Bring out the enema tray to the central, clean and keep the equipment used in its proper place. 14. Return to check on the patient in about 10 minutes. Such not prevent irritation or fatigue due to waiting on the bedpan. 15. Empty the bedpan. Before emptying it, note the return flow, especially considering the purpose of the enema, the amount, consistency and color, unusual odor or appearance, any abnormality (blood, mucus, parasite) amount of flatus expelled. Adequate and accurate observations guide the doctor in diagnosis and his plan of care. 16. Give external douche, then dry the buttocks. Remove rubber protector changed soiled linens and make him comfortable. Measures to prevent odor and to provide comfort and much to the psychological reassurance of the patient. Wash the hands of the patient if he did his own cleaning. Microorganisms maybe transferred thru contaminated hands. Allow free ventilation; leave the unit in order. Good ventilation eliminates unpleasant efforts of gases expelled during bowel movements. RECORD: • Time and time of treatment • Kind of amount of solution used • Amount and character of the return flow (amount, consistency, color, appearance) • Any abnormality observed • Patient's reaction to treatment B. RETENTION ENEMA
- 5. Special considerations: 1. If it is intended to supply food or fluid, or to administer a medication or treat the colonic mucosa, make sure that the rectum is free of feces. 2. Avoid stimulating peristalsis by: a. Keeping the bedpan out of the patient's sight. b. Introducing the solution under low pressure. c. seeing to it that the temperature of the solution is correct. 3. If the enema is medicinal, see to it that the drug is well dissolve. 4. Ensure the patient's cooperation by explaining the purpose of the treatment. PREPARATION: A. Equipment: A tray with • Graduated pitcher • Prescribed solution - should be heated to the desired temperature of 150-110 F • Funnel or barrel of a 50 cc. • Syringe • Tissue paper • Rectal tube - Rr. 16-18 • Kidney basin • Lubricant • Rubber protector B. PATIENT AND UNIT - same as in non-retention enema. Procedure Proceed as in non-retention enema up to # 3 4. Attach the rectal tube to the funnel or tip of a 50-cc. syringe. Lubricate the tip of the rectal tube. 5. Holding the funnel with the left hand and kinking or pinching it near the point of attachment, pour some solution to the funnel or syringe barrel, and allow it to flow to the tip of the rectal tube. 6. Pinch the tube again and insert about 4-6 inches into the rectum gently with a rotating motion. Instilling the solution well above the internal anal sphincter by inserting the tube high enough to prevent the stimulating of defecation. Such motion prevents discomfort which may result in the non-retention of the solution. 7. Let the solution flow into the rectum slowly and under low pressure holding the funnel in such a way that the level of the solution is about 12 in. above the rectum. Stop the flow occasionally. To aid in the retention of the solution. 8. When the solution is consumed, pinch the rectal tube closes to the anus and withdraw it slowly. Wrap its end with tissue paper, detach it from the funnel or syringe barrel and place it in a kidney basin. 9. Apply light pressure over the anal region or hold or press the buttocks together for a few minutes or two. Such action allays desire to defecate. 10. Advise the patient to stay quiet and to remain on the same position for 15-20 min. or until the sensation to move the bowels has passed. Movement stimulates peristalsis. 11. Bring out the used equipment leaving the rubber protector under the buttocks for some time. Clean the equipment used and return to its proper place. Prompt cleaning and sterilization of equipment used to prevent spread of microorganisms and its availability. 12. Return to check on the condition of the patient. Observed the results considering the purpose of the enema.
- 6. Remove the rubber protector and make the patient comfortable. Leave the unit in order. RECORD: • Time and kind of treatment. • Amount and kind of solution. • Duration of retention. • If solution is expelled, how much and after what length of time. • Reaction of the patient.